CSD benefits/services rev 06262015
BENEFITS/SERVICES PROVIDED www.schooldistrictbenefits.com/christina
ENROLLMENT DEADLINE The Benefit Enrollment Packet must be completed and returned as soon as possible but no later than 30 days
from hire date. If enrollment forms and documents are not signed and returned within 30 days, benefits will be
“waived” in accordance with 3.01 of State of Delaware regulations.
SUMMARY PLAN DESCRIPTION, BENEFITS VIDEO & PROVIDER DIRECTORIES
The Summary Plan Description, informational video, enrollment forms and participating provider directories
can be found online at www.schooldistrictbenefits.com/christina.
STATE OF DELAWARE BENEFITS
Medical Insurance with Prescription Drug plan -The State of Delaware provides a state share for permanent
employees working 30 hours or more per week, after 3 months of service. The District will pay a medical
stipend (flex credit) the first day of the month following the hire date based on negotiated contractual
agreements. First State Basic, Gold, HMO, IPA/HMO or Comprehensive PPO plans with Express Scripts
prescription is included at no extra cost to the employee. The State wide benefits web site is
http://ben.omb.delaware.gov/
Blood Bank-Blood Bank of Delmarva Members for Life Program is available to all employees for information go to
www.ben.omb.delaware.gov/blood/.
Contributory Pension Plan-State Pension Plan provides Service, Disability, and Vested Pensions. Employees
are vested after completing 10 years of State of Delaware service. Employees are required to contribute 5 % of
earnings above $6000.00 annually. Employees may elect to withdraw their contributions upon termination of
District employment. The State Pension Plan summary is available at www.delawarepensions.com.
State Disability Insurance-Short and Long-term benefits provided by the State at no cost to the employee.
http://ben.omb.delaware.gov/disability/
State Group-Minnesota Life Insurance-Employees can purchase 1-to 6 x annual salary, after 3 months of
service. Dependent insurance is also available. Enrollment information will be mailed to your home address.
Rates vary based on age and coverage elections.
http://www.schooldistrictbenefits.com/christina/stategrouplife.htm
AFLAC Supplemental Insurance – AFLAC Group Accident Advantage Insurance and/or Group Critical Illness
Insurance is available to employees. Information at the State wide benefits web site http://ben.omb.delaware.gov/
State Deferred Compensation (457 pretax retirement plan)-A State sponsored retirement savings plan through
Fidelity Investment Services with over 250 funds to choose from. For more information contact Fidelity at 800-
430-2363.http://treasurer.delaware.gov/deferred_compensation/
Flexible Spending Account-Health/Dependent Care pre-tax flexible spending account. Health Care Spending
Account election available for up to $2,500 annually for eligible out-of-pocket medical, dental and prescription
drug expenses incurred by you or your dependents(s). Dependent Care Spending Account election available for
up to $5,000 annually per household for eligible child or dependent care expenses while you are working.
Eligible after 3 months of service. For more Flexible Spending Account information contact ASI at 1-800-659-
3035 or visit www.asiflex.com. http://ben.omb.delaware.gov/fsa/index.shtml
CSD benefits/services rev 06262015
BENEFITS/SERVICES PROVIDED www.schooldistrictbenefits.com/christina
STATE OF DELAWARE BENEFITS CONTINUED
Employee Assistance Program (EAP)-Human Management Services, Inc. offers confidential assistance
for personal and family matters to employees and their dependents enrolled in the health insurance plan.
To receive an assessment and up to 5 short-term counseling sessions free of charge contact HMS at
1-800 343-2186 or visit www.hmsincorp.com. Member Log in: State of Delaware
CHRISTINA SCHOOL DISTRICT LOCAL BENEFITS
A District stipend (flex credit), based on contractual agreement, is provided to purchase the following District
Benefits:
District Dental Insurance-Met-Life dental coverage pays benefits for many preventive and corrective dental
services for employee and eligible dependents. There are 2 option levels. The customer service number for Met-
Life is 1-888-303-1113. Claim forms are available online at www.schooldistrictbenefits.com/christina.
District Group Life/Accidental Death & Dismemberment Insurance-This life insurance covers the employee for
an amount 2 times annual salary (up to age 65). The customer service number for Reliance Standard is 1-800-
351-7500 or online at www.schooldistrictbenefits.com/christina.
District Group Long Term Disability Insurance- Enhances State long-term disability plan by providing the
employee 6 2/3% buy-up option, after meeting the 182 day elimination period and approval. The customer
service number for The Hartford is 1-800-538-8439.
District Vision Insurance- Vision coverage for employee and eligible dependents which includes exams, lenses,
frames or contacts. Participating Providers are all electronic, claim forms will only be needed for Non-
Participating Providers and must be ordered prior to receiving services by contacting Vision Benefits of
America (VBA) at 1-800-432-4966 or online at www.schooldistrictbenefits.com/christina.
DEPENDENT ELIGIBILITY/AGE LIMITS Dependents are eligible for Medical/Express Scripts Prescription, Dental and Vision coverage through the end
of the month age 26 is reached.
OTHER SERVICES OFFERED
Credit Union-Employees may join the New Castle County School Employees Federal Credit Union.
Checking/Savings accounts, reduced rate interest loans and Visa Credit Card Accounts, Vacation/Christmas
Club Accounts. To become a member contact (302) 613-5330.
TSA- (403b retirement plan)-Voluntary pretax payroll deduction to an approved Tax Sheltered Annuity account. Vendor
approved list available at http://treasurer.delaware.gov
www.schooldistrictbenefits.com/christina Ben calc 2015-2016 rev 060315
District Dental Insurance (Metlife)
Plan A Plan B
1. Employee Only $ 738.24 $ 577.20
2. Employee & Spouse $1,162.56 $ 899.76
3. Employee & Children $1,444.08 $1,116.24
4. Family $1,978.32 $1,530.00
Annual Cost Of Plan Selected
$_____________
District Vision Care (Vision Benefits of America)
1. Employee Only $ 161.52
2. Employee & Spouse $ 302.40
3. Employee & Children $ 273.60
4. Family $ 420.48
$_____________
District Life Insurance (Reliance Standard)
2.0 x annual salary x $0.139 per $1,000 (Insurance benefit rounded to next $500)
$_____________
District Long-Term Disability (The Hartford)
LTD buy up for employees covered in the State disability program Rate for employees to buy up from 60% to 66 2/3%, beginning on the 182nd day of disability: $0.15 (per $1,000 of covered payroll)= monthly x 12 = Annual
(The LTD benefit is capped at $8,000 per month)
$_____________
Blood Bank
Free to all employees
$_____________
TOTAL ANNUAL BENEFITS COST OF PLANS SELECTED ABOVE: $______________ LESS BOARD CONTRIBUTION (Flex Credits) (Please refer to your current union contract) $______________ YOUR ANNUAL COST OF BENEFITS (Annual cost less flex credits) $______________ DEDUCTION PER PAY (divide total annual cost of benefits above by 24 pay) $______________
Benefits Cost Worksheet
2015-2016
Example: Annual Salary: $28,000 Amount of benefit: 2.0 x 28,000 = $56,000
Amount per pay: 56.0 x 0.139 = 7.784 Annual cost: 7.784 X 24 = $186.82
Rev06/26/2015
REQUIRED BENEFIT FORMS CHECK LIST ••NEW HIRE••
PLEASE DO NOT SEPARATE THIS BENEFIT ENROLLMENT PACKET THIS PACKET MUST BE COMPLETED AND RETURNED TO THE BENEFITS OFFICE AS SOON AS POSSIBLE, BUT NO LATER THAN 30 DAYS FROM HIRE DATE. IF THIS ENROLLMENT PACKET AND REQUIRED DOCUMENTATION ARE NOT RETURNED WITHIN 30 DAYS OF HIRE DATE, BENEFITS WILL BE WAIVED IN ACCORDANCE WITH STATE REGULATIONS.
________________ Employee Benefit Enrollment Form (check (√) ALL sections must be completed, signed and dated. ________________ Dependent Enrollment/Application Form – All sections must be completed, signed and dated. ________________ Spousal Coordination of Benefits Policy Form (If covering a spouse) – must be completed online to insure spouse’s coverage at 100% _____ • Copy of Marriage/Civil Union certificate is required if enrolling a spouse _____ • Copy of Birth certificate is required for each dependent child you are enrolling for the first time.
Note: Dependent Coordination of Benefits Form - A Dependent Coordination of Benefits Form must be completed for each enrolled dependent child regardless of age if child has other Active Health Insurance and for any dependent child upon request by the Statewide Benefits Office or the State of Delaware GHIP health care carrier
_______________ District Life/A D &D Beneficiary Form – (Complete, sign and date) _______________ ASI Flex (Complete application or Refuse and sign and date) _______________ Pension Actuarial Information Form (Complete ALL information on both sides, sign and date) _______________ W-4 Form- (Complete, sign and date) _______________ Direct Deposit Form – (Form required-mandatory condition of employment) _______________ Certification of Tax Dependent Status for A Civil Union Spouse/Children (Complete only
if adding Civil Union Family members) if applicable
Questions?? www.schooldistrictbenefits.com/christina EMPLOYEE NAME _______________________________SOCIAL SECURITY#________________ (Please Print)
SIGNATURE _____________________________________SCHOOL________________________________
EMPLOYEE BENEFIT ENROLLMENT FORM 2015-16
Date of Hire/Change________________________
EMPLOYEE LAST NAME FIRST NAME/INITIAL BIRTHDATE EMPL ID SOC. SEC. NO.
LOCATION CLASSIFICATION SALARY # PAYS STIPEND
SPOUSAL COORDINATION OF BENEFITS FOR HEALTH COVERAGE
Does your spouse work for OR retired from STATE OF DELAWARE Agency?
YES NO Spouse’s Name: _____________________________________________ Spouse’s SSN: _____________________________
If Yes: Agency Name:_____________________________ Spouse’s Birth Date:_________________ Spouse’s Hours Worked Per Week______________
You MUST Select or (√) No Coverage for each plan:
<STATE BENEFITS> MEDICAL Express Scripts Prescription included with these plans
Employee Employee & Spouse Employee & Children Family
Highmark Delaware – First State Basic
Highmark Delaware – Comprehensive PPO
Highmark Delaware –IPA/HMO
Highmark Delaware – CDH Gold
Aetna HMO
Aetna CDH Gold
NO Coverage
BLOOD BANK YES NO
FLEXIBLE SPENDING ACCOUNT (Application Required)
Eligible after 90 day waiting period YES NO
<DISTRICT BENEFITS> (Annual Plan Cost)
MET LIFE DENTAL Employee Employee & Spouse Employee & Children Family
Plan A $ 738.24 $ 1,162.56 $ 1,444.08 $ 1,978.32
Plan B $ 577.20 $ 899.76 $ 1,116.24 $ 1,530.00
NO Coverage
Vision Benefits of America Employee Employee & Spouse Employee & Children Family
$ 161.52 $ 302.40 $ 273.60 $ 420.48
NO Coverage
Copays $10 Vision Exam $25 Lenses and/or Frames
District LIFE/AD&D INSURANCE (Reliance Standard) 2 x Annual Salary (Beneficiary Form Required)
$ ______________ of Coverage $ _____________________ Approximate Annual Cost Calculation Example: Salary $28,000. X 2 = $56,000. Coverage
56.0 x 0.139 = 7.784 X 24 = Annual Cost of $186.82
NO Coverage
HARTFORD SUPPLEMENTAL DISABILITY 6 2/3 monthly benefits after 182-day elimination period ($8,000.00 maximum) Calculation : $0.15 (per $1,000. of covered payroll)= monthly X 12 = Annual
NO Coverage
REQUIRED INFORMATION: PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM. BENEFITS WILL NOT BE PROCESSED IF INFORMATION/SIGNATURE IS MISSING AND/OR THE REQUIRED FORMS ARE NOT SUBMITTED, FAILURE TO SUBMIT REQUIRED FORMS CAN ALSO RESULT IN A DELAY OF YOUR PAYCHECK.
Complete benefit enrollment form (previous page) selecting your benefits.
Complete dependent enrollment/application form indicating benefit selections for each
covered dependent (including self and spouse) for Medical, Dental, Vision, {*Please
see State Eligibility and Enrollment rules at http://ben.omb.delaware.gov/documents/eer-070113.pdf
Complete Dependent Coordination of Benefits form for each dependent child regardless of age if
child has other Active Health Insurance.
Complete spousal coordination form online, if enrolling spouse in health coverage at
http://www.employeeselfservice.omb.delaware.gov/
Submit copy of Marriage/Civil Union Certificate if enrolling a spouse for the first time
Submit copy of Birth Certificate if enrolling a dependent for the first time
Complete beneficiary form in enrolling in the District Life Insurance Program.
CERTIFICATION (everyone must sign and date) By my signature below, I hereby certify that the benefit elections I have made on this form are the benefit elections I have chosen, and
that I have completed the required forms necessary to enroll. I understand that by completing and signing the required forms, I am
making a binding election with regard to my benefits for the current plan year unless I have a permissible status change as defined by the
Internal Revenue Service or I terminate my employment with the State of Delaware. I understand and agree my regular pay will be
reduced by the amount of my required contribution for the benefit options I have elected. I understand if employment ends I am eligible to
continue District Life Insurance by contacting the insurance carrier within 30 days of termination date for conversion to an individual
coverage.
NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health
coverage, you may in the future be able to enroll yourself and your dependents in this plan if you or your dependents lost eligibility for
that other coverage (or if the employer stops contributing towards you or your dependents’ other coverage). However, you must request
enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contributing toward the other
coverage).
In addition, if you have a change of employment status, new dependent as a result of marriage, birth, adoption or placement for adoption,
you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth,
adoption or placement for adoption.
Note: A federal law called HIPAA requires the State of Delaware Group Health Plan (the “Plan”) provide a Certificate of Creditable
Coverage (a “Certificate”) to each individual who requests one so long as it is requested while the individual is covered under the Plan or
within 24 months after the individual’s coverage under the Plan ends. The Procedure to Request a Certificate of Creditable Coverage is
available by contacting your Benefits Office.
State/District Policy: I understand after this date, I will not be able to make changes to any State and/or District Benefit Plans (Health,
Dental, Vision, Life or Disability) for the remainder of the enrollment period unless I experience one of the following “Qualifying
Events”:
• Change in employment status (1/2 time to full time, full time to ½ time, teacher to administrator)
• Change in Marital Status or Dependent Status (birth/adoption)
• Spouse’s loss of coverage
I understand that it is my responsibility to notify the Benefits Office within 30 days of a “qualifying event” to make changes to my Benefit
Plans. Failure to notify the Benefits Office within 30 days of the “Qualifying event” will result in waiting until the next Annual Open
Enrollment Period to make changes.
NAME: _______________________________________________________DATE:__________________ Questions?? www.schooldistrictbenefits.com/christina
Or e-mail [email protected] Rev.10092014
Rev. 06032015
DEPENDENT ENROLLMENT/APPLICATION FORM
EMPLOYEE INFORMATION Please Note: Benefits will not be processed if this form is incomplete
Name Address Home Telephone# Cell #
Social Security # Work Location Work #
HEALTH COVERAGE PLANS (select plan choice and coverage type below) □ REFUSING HEALTH COVERAGE Highmark DE □ First State Basic □ Comprehensive PPO □ IPA/HMO □ CDH Gold □ AETNA HMO □ Aetna CDH Gold
COVERAGE TYPE: □ Employee □ Employee & Spouse □ Employee & Child(ren) □ Family
ENROLLMENT INFORMATION List dependents (including SELF & spouse) and benefit plan code selections below Dependent’s/ Name Dependent’s
Social Security # Birth Date
Plan Code M=State Medical &
Prescription D=Dental V=Vision
M D V
Primary Care Name For Aetna HMO
Primary Physician’s ID #
for IPA/HMO
Relation Sp=Spouse
D =Daughter S= Son
Adult Dependent Age 21-26
Disabled Child
SELF
DENTAL ENROLLMENT (select plan choice) □ PLAN A □ PLAN B
COVERAGE TYPE: □ Employee □ Employee & Spouse □ Employee & Child (ren) □ Family □REFUSING DENTAL COVERAGE
Medical Dependent Coverage ends: End of month age 26 is reached Express Scripts State Prescription Coverage ends: End of month age 26 is reached Dental & Vision Dependent Coverage ends: End of month age 26 is reached
_____________________________________________ _________________ _______________
Employee Signature Date Employee ID#
Spousal Coordination of Benefits Form
If you cover your spouse in one of the State of
Delaware Group Health Insurance medical
plans you must complete a Spousal
Coordination of Benefits form online at:
http://www.employeeselfservice.omb.delaware.gov/
COORDINATION OF BENEFITS QUESTIONNAIRE
COB-003 (10-12)continued on reverse side
Your Name: __________________________________________ Social Security #:______________________
A. Within the past year, have you or any member of your family been covered by another insurance company?q No. Please complete question C, if applicable.q Yes. Please complete the remainder of this questionnaire.
B. Check which of the following plans provide benefits for you or any member of your family:
q Another Highmark Blue Cross Blue Shield Delaware contract?
ID #: _________________________________________
q Medicare?
HIC #: _________________ Part B effective date (mo., day, yr.): _______________________________________
q Another health insurer?
Name of other health insurance company: ________________________________________________
Name of other employer: _______________________________________________________________
Address where claims are submitted: _____________________________________________________
Name of policyholder: _________________________________________________________________
Policyholder’s date of birth (month, day, year): ______________________________________________
Policyholder’s ID #: ____________________________________________________________________
Effective date of policy (month, day, year): __________________________________________________
Cancellation date, if applicable (month, day, year): ___________________________________________
Name of persons covered:
Spouse: ______________________________________________________________________________
Dependent child(ren): __________________________________________________________________
q Another dental policy?
Name of dental carrier: _________________________________________________________________
Effective date of dental policy (month, day, year): ____________________________________________
If dental policy is canceled, date (month, date, year): _________________________________________
Who is covered under this policy? q Policyholder q Spouse q Dependent child(ren)
Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association
C. The following information must be provided as required by our Employer’s Coordination of Benefits (COB) Policy. (Check with your employer.)
My spouse is: q Not employedq Employed full-time
q Employed part-time
q Self-employed
q Retired
Name of spouse’s employer: ___________________________________________________
Is medical insurance offered? q Yes q No
Percent of premium, if any, paid by spouse? ___________________________________________________
If spouse is self-employed, what percent is paid by his/her employees? ____________________________
Renewal date of spouse’s medical insurance plan: ______________________________________________
Your signature: __________________________________________________________________________
Daytime telephone number: ( ) _______________________________
Identification #: __________________________________________________________________________
COORDINATION OF BENEFITS QUESTIONNAIRE continued
Please return this survey to:Highmark Delaware
P.O. Box 1991Wilmington, DE 19899-1991
We thank you for the time spent completing this questionnaire.The information provided will help us to process your claims.
State of Delaware
Office of Management and Budget, Statewide Benefits Office
Dependent Coordination of Benefits Form
Section A: Member Name: __________________________________________________
Aetna member ID Number or Social Security Number: ________________________
Do any of your children have other health care coverage?
_____ No…please check this line and sign this form at bottom.
_____ Yes…please complete Sections B and C below and sign this form at bottom.
Section B: Please complete this section concerning your child/ren’s other coverage. If all children have the same
coverage, please list each child’s name; if children have different coverage, please prepare a separate
form for each child.
_____ Child/ren is covered by another Aetna plan and ID Number is ___________
_____ Child/ren is covered by another health insurance plan.
Name of the other health insurance plan is ____________________________________
Name of policyholder: __________________________________Birth date__________
Name of employer _______________________________________________________
Effective date of coverage: ________________ Date, if cancelled: ________________
Names of child/ren covered and birth date:
Child: _________________________________________________________________
Child: _________________________________________________________________
Child: _________________________________________________________________
If divorced, which parent has primary, physical custody? _____ Mother _____ Father
Thank you for completing this form, your responses will enable claims to be processed properly.
Your signature: ______________________ Daytime Phone Number: ______________
Please print this form, complete, and mail or fax to the following:
Aetna
PO Box 981106
El Paso, TX 79998-1106
Fax# 859-455-8650
STATE OF DELAWARE Flexible Spending Account
Enrollment Agreement 2015 Plan Year
As an employee eligible to participate in the State of Delaware’s Flexible Spending Account program within the current
Plan Year (calendar year 2015), I have reviewed the 2015 Guide to Your FSA Benefits and understand the benefits
available to me as well as the other rights and obligations I have under the plan. I understand this Agreement is
irrevocable during this plan year except under special circumstances as outlined in the Guide. I also understand that I will
have until April 15th, 2016 to submit claims for reimbursement for services received during the plan year or coverage
period. Any unused amounts remaining in my account at the end of this specified period of time will be forfeited. This
Agreement is subject to the terms of the State of Delaware Flexible Spending Account Plan. I hereby request to
participate in the Health Care Account and/or Dependent Care Account with the plan year election/s as indicated below
and authorize my annual taxable salary to be adjusted based on my election/s for the remaining pay periods in this plan
year. I understand that this request is for the current plan year and it is my responsibility to enroll to participate in future
open enrollment periods for future plan years.
Employee I.D. Number ______________________
Name _________________________________________________ ____________________________________________
(Last, First MI) Agency/School District Name
Street _________________________________________________ ____________________________________________
Employee Daytime Phone Number City, State, Zip _________________________________________________
Plan Year Election
Health Care Flexible Spending Account $___ __________________ (Minimum $50, Maximum $2,550)
Dependent Care Flexible Spending Account $___ __________________ (Minimum $50, Maximum $5,000)
* Your plan year election will be divided by the number of pay dates remaining in the calendar year. * DIRECT DEPOSIT REIMBURSEMENT enrollment information is available at www.ben.omb.delaware.gov/fsa.
Employee's signature: ________________________________________________ Date:_________________
Please contact Statewide Benefits Office, at 1-800-489-8933 with questions.
Return this form to Statewide Benefits Office by fax, (302) 739-8339
Form No. P-1 (5/15) Email: [email protected] www.delawarepensions.com Toll Free Number Outside State of Delaware 1 - 800 - 722 – 7300
Office of Pensions McArdle Building
860 Silver Lake Blvd, Suite 1 Dover, DE 19904-2402
Telephone: (302) 739 - 4208
STATE OF DELAWARE
MEMBER ACTUARIAL INFORMATION
PERSONAL DATA: To be completed by Member (Please Print)
1. _____________________________________________________________________________________ 2. Soc. Sec. No.: _____________________________ (Last Name) (First Name) (M.I.) (Maiden Name)
3. Address: _____________________________________________________________________________ 4. Telephone No.: _____________________________ (Number) (Street) (City) (State) (Zip Code)
5. Date of Birth: _____________________ 6. Gender: Male Female 7. Marital Status: Married Civil Union Single (Month / Day / Year) (Choose One) (Choose One)
8. Organization: ________________________________________________________ Department ID: ________________________________________________
9. Pension Plan: (Check One): State Employees’: State Police: Judiciary: Legislative:
C/M Police/Fire: C/M General: (LOSAP) Fire: Port: 10. Effective Date of Hire with Present Organization: ______________________________________ 11. Current Annual Salary: ________________ 12. Have you previously been a member of any State of Delaware State Sponsored Pension Plan: Yes No If YES, complete list below:
(INCLUDE LEAVES OF ABSENCE PRIOR SERVICE CLAIMED AND INDICATE REASON)
NAME OF ORGANIZATION
FROM MONTH YEAR
THROUGH MONTH YEAR
PERIOD COVERED YEARS MONTHS
TOTAL PRIOR SERVICE CLAIMED (ADD)
13. (a) Did you serve in the Armed Forces of the United States: Yes No (b) If (a) is YES, show total Active Military Service: FROM ________________________ TO _________________________ TOTAL CREDIT ________________________
(c) Did you begin a full-time vocational or professional training course within 5 years of your discharge and become a State employee within 5 years after the completion of that training: Yes No
(d) If (c) is YES, show full-time vocational or professional training course dates, and date degree, diploma, or certificate granted: FROM ________________________ TO _________________________ DATE OF DEGREE _________________________
14. Have you ever rendered full-time service in professional educational employment or other full-time employment for another State or the Federal Government, a county or municipality of the State of Delaware, a political subdivision of another State, or in an accredited private school or college: Yes No If YES, complete list below:
NAME OF ORGANIZATION
FROM MONTH YEAR
THROUGH MONTH YEAR
PERIOD COVERED YEARS MONTHS
15. Are you eligible for benefits as a result of any service listed in No. 14 above: Yes No DEPENDENT DATA: (This information must be filled out if you are married or in a civil union.) 16. Name of Spouse: _____________________________________________________________________________________ Gender: Male Female (Last Name) (First Name) (M.I.) (Maiden Name) _______________________________________________________________________________________ Telephone No.: __________________________ (Street Address) (City) (State) (Zip) Date of Birth: ____________________ Soc. Sec. No.: _________________________ Date of Marriage/Civil Union: ______________________ (Month/Day/Year) (Month/Day/Year)
17. Dependent Child(ren) or Dependent Parents ( Fill in only if parent(s) are receiving at least one-half of his or her support from you) : Name: _____________________________________________________ Date of Birth: ________________ Soc. Sec. No.: __________________________ Address: _______________________________________________________________________________ Telephone No.: __________________________ Gender: Male Female Disabled: Yes No Dep. Child: Dep. Parent: Relationship: __________________________ Name: _____________________________________________________ Date of Birth: ________________ Soc. Sec. No.: __________________________ Address: _______________________________________________________________________________ Telephone No.: __________________________ Gender: Male Female Disabled: Yes No Dep. Child: Dep. Parent: Relationship: __________________________ Name: _____________________________________________________ Date of Birth: ________________ Soc. Sec. No.: __________________________
Address: ______________________________________________________________________________ Telephone No.: __________________________ Gender: Male Female Disabled: Yes No Dep. Child: Dep. Parent: Relationship: __________________________ Name: _____________________________________________________ Date of Birth: ________________ Soc. Sec. No.: __________________________ Address: ______________________________________________________________________________ Telephone No.: __________________________ Gender: Male Female Disabled: Yes No Dep. Child: Dep. Parent: Relationship: __________________________
DESIGNATION OF BENEFICIARY FOR PAYMENT OF PENSION CONTRIBUTIONS IF NO SURVIVOR’S PENSION IS PAYABLE
18. (If more than one name is listed, payment will be divided equally, unless otherwise specified.) Primary/Contingent Name: __________________________________________________ Date of Birth: _________________ SSN or EIN: _________________ Address: ______________________________________________________________________________________________ Telephone No.: ________________ Relationship: _________________ Gender: Male Female Primary/Contingent
Name: __________________________________________________ Date of Birth: __________________ SSN or EIN: ________________
Address: ______________________________________________________________________________________________ Telephone No.: ________________ Relationship: _________________ Gender: Male Female Primary/Contingent
Name: __________________________________________________ Date of Birth: __________________ SSN or EIN: ________________
Address: ______________________________________________________________________________________________ Telephone No.: ________________ Relationship: _________________ Gender: Male Female Primary/Contingent
Name: __________________________________________________ Date of Birth: __________________ SSN or EIN: ________________
Address: ______________________________________________________________________________________________ Telephone No.: ________________ Relationship: _________________ Gender: Male Female
DATE: _________________________________ SIGNATURE OF MEMBER: ________________________________________________________________
(Month/Day/Year)
(Month/Day/Year)
(Month/Day/Year)
(Month/Day/Year)
PHRST PAYROLL REQUEST Direct Deposit Authorization Form
P8110 Direct Deposit Authorization Revised: 5/20/2014
Please return to your Human Resource or Payroll Department Date:
Employee Name: Empl ID: Work Phone:
Direct Deposit Instructions: If only one banking instruction is set up, Section A designates the account to receive the balance of net pay. If there are multiple banking
instructions in Section B, then Section A designates the account to receive any balance funds left over after all other direct deposit instructions are
processed. The priority number of 999 is established for the account in Section A. For multiple accounts, all accounts with the exception of the last
account (Section A) shall be processed as Flat Amount and shall be designated by Priority beginning with 100, 200, etc. in Section B.
Section A: Balance Account: The following account is either the only account to be used for Direct Deposit or the account which is to receive the
net amount remaining after all other deposits have been made as indicated in Section B, the list of Additional Accounts.
999 Balance Priority Amount Transit # Account # Checking Savings
Bank Name:
Bank Address:
Section B: Additional Accounts For Multiple Direct Deposits
Priority Flat Amount Transit # Account # Checking Savings
Bank Name:
Bank Address:
Priority Flat Amount Transit # Account # Checking Savings
Bank Name:
Bank Address:
Priority Flat Amount Transit # Account # Checking Savings
Bank Name:
Bank Address:
I hereby authorize the State of Delaware to deposit my net pay to the financial institution(s) listed above. I understand my net pay will be deposited
to my designated account(s) so the funds are available to me on the day of pay. In the event funds to which I am not entitled are deposited to my
account(s), I hereby authorize the State of Delaware to direct the bank to return said funds.
Direct Deposit of my net pay will remain in effect until my employment with the State of Delaware is terminated. The State may terminate this
service at any time. These Direct Deposit instructions replace any previously dated instructions.
Employee Signature: Date:
YOU ARE RESPONSIBLE for ensuring the routing and account numbers on this form are correct.
Please contact your bank to confirm routing/account numbers if you are unsure.
INCORRECT OR ILLEGIBLE ROUTING AND/OR ACCOUNT NUMBERS
WILL RESULT IN YOUR PAY BEING DELAYED.
CERTIFICATION OF TAX DEPENDENT STATUS FOR A CIVIL UNION SPOUSE/CHILDREN
State of Delaware
This form must be completed and signed by the employee when enrolling a civil union spouse and/or the civil union spouse’s children in the State of Delaware Group Health Insurance Program. Employee Name: __________________________________________________________________________________
Employee ID: _________________ For a civil union spouse and children of a civil union spouse to be a dependent for health plan purposes, certain requirements in Internal Revenue Code (“IRC”) § 152 (as modified by IRC §105(b)) must be satisfied. The civil union spouse and children of the civil union spouse must, in general:
1. Receive at least one half of his/her support from you; 2. Live with you in the same principal place of abode as part of your household; 3. Not be claimed as a “qualifying child” dependent under IRC § 152(c) by anyone else (generally, a qualifying child is a dependent
under age 19, age 24 if a full-time student, that meets certain requirements); 4. Be a U.S. citizen, a U.S. national, or a resident of the U.S., Canada or Mexico at some time during the year in which you are
claiming him/her as a dependent; and, 5. Not file a joint federal income tax return (other than only a claim of refund) with the individual’s spouse (applicable to children
of civil union spouse).
If you select “Is a tax-qualified dependent,” you are certifying the named person is a dependent described in IRC §152 (as modified by IRC §105(b)). If you select “Is not a tax-qualified dependent,” you are certifying (1) the named person is not a dependent described in IRC §152 (as modified by IRC §105(b)) and (2) you understand federal tax law requires the fair market value of the coverage extended to the named person to be imputed to you as income on your paycheck and must be reflected on the W-2 issued to you by the State of Delaware. Notify your Human Resources/Benefits Office in writing immediately of any changes in the named person’s tax status and complete this form to provide change in status.
Name Date of Birth Tax Dependent Status Civil Union Spouse:
____/____/____ Is a tax-qualified dependent Is not a tax-qualified dependent
Civil Union Spouse’s Children:
____/____/____
Is a tax-qualified dependent Is not a tax-qualified dependent
____/____/____
Is a tax-qualified dependent Is not a tax-qualified dependent
____/____/____
Is a tax-qualified dependent Is not a tax-qualified dependent
____/____/____
Is a tax-qualified dependent Is not a tax-qualified dependent
I understand federal income tax dependent status is separate from eligibility for health benefits. A designation as an dependent described in IRC §152 will result in the State of Delaware not reporting imputed income for the value of those benefits to the IRS for me. As a result, I understand the brief description of a federal income tax dependent above is a general summary, and I should contact my tax advisor before signing this form. I also understand falsely certifying to the tax-dependent status of any person may result in adverse tax consequences and potential charges of tax fraud. In accordance with my completion of this form, I am requesting my Human Resources/Benefits Office use the following coverage code for enrollment of my civil union spouse and/or civil union spouse’s children for health plan purposes: _______________ (See attached Coverage Code Explanations for complete listing of coverage codes.) Employee’s signature: _______________________________________________________ Date: ___________________________
CU Doc #2 9-13-13
State of Delaware Group Health Insurance Program Coverage Code Explanations
Civil Union Spouses and/or Civil Union Spouse’s Children
Following the Coverage Code letter and description will be a listing of the types of dependents covered under this code:
I – Emp & IRSNQ Spouse • Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS
J – Emp & IRSNQ Child • Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS
K – Emp & IRSNQ Spouse + NQ Child(ren) • Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS
M – Emp & IRSQ Spouse
• Civil Union Spouse who is qualified to be employee’s tax dependent by IRS
N - Emp & IRSQ Child • Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
O – Emp & IRSQ Spouse + QChild(ren) • Civil Union Spouse who is qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
P – Emp+Child & IRSNQ Spouse
• Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS
R – Emp+Child & IRSNQ Child(ren) • Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or
Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS S – Emp+Child & IRSNQ Spouse + NQChild(ren)
• Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS
Civil Union Coverage Code Explanations 2
CU Doc #2 9-13-13
T - Emp+Child & IRSQ Spouse • Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or
Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is qualified to be employee’s tax dependent by IRS
U - Emp+Child & IRSQ Child(ren) • Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or
Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
V - Emp+Child & IRSQ Spouse + Q Child(ren) • Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or
Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
W – Emp & IRSNQ Spouse + Q Child(ren)
• Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
X - Emp & IRSQ Spouse + NQ Child(ren)
• Civil Union Spouse who is qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS
Y - Emp+Child & IRSNQ Spouse + QChild(ren)
• Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is not qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are qualified to be employee’s tax dependents by IRS
Z - Emp+Child & IRSQ Spouse + NQChild(ren)
• Employee’s son, daughter, adopted son, adopted daughter, or foster son or daughter (and/or Employee’s grandchild, niece nephew, etc. who are tax dependents as defined in Group Eligibility Rule 2.01c).
• Civil Union Spouse who is qualified to be employee’s tax dependent by IRS • Children of Civil Union Spouse who are not qualified to be employee’s tax dependents by IRS
Civil Union Coverage Code Explanations 3
CU Doc #2 9-13-13
T/Civil Unions for 1-1-12/CU SGM Web Pieces for 10-13/CU Doc#2.Coverage Code Explanation 9-13-13 Revised 7-1-13 Revised 9-13-13
DESIGNATION OR CHANGE OF BENEFICIARY FORM Local Life Insurance
- - Name of Employee Occupation Social Security Number
Male
Female Date of Birth Date of Employment Primary Beneficiary (ies): Name:
Name:
Address:
Address:
Relationship:
Relationship:
Date of Birth:
Date of Birth:
Social Security Number:
Social Security Number:
List contingent beneficiaries below. Benefits are payable in equal shares to the primary beneficiary (ies) shown, if living, or to the survivors, otherwise to the named contingent beneficiary (ies) in equal shares or to the survivors unless otherwise specified. Employee Signature Date The right is reserved to revoke this designation and to designate new beneficiaries at any time by filing a new designation or Change of Beneficiary Form. This request and authorization applies to any such plan of insurance as presently constituted or hereinafter changed for which I am or may become eligible and shall continue to apply until rescinded by me in writing. Contingent Beneficiary (ies): Name:
Name:
Address:
Address:
Relationship:
Relationship:
Date of Birth:
Date of Birth:
Social Security Number:
Social Security Number:
Name:
Name:
Address:
Address:
Relationship:
Relationship:
Date of Birth:
Date of Birth:
Social Security Number:
Social Security Number:
State of Delaware
Executive Department Office of Management & Budget
January 6, 2014 Dear Employee, Enclosed is a Notice entitled “New Health Insurance Marketplace Coverage Options and Your Health Coverage.” The health care reform law known as the Affordable Care Act (“ACA”) requires that employers provide this Notice to all new employees within 14 days of hire. The Notice provides information about the new Health Insurance Marketplace (“Marketplace”), as well as information regarding the health coverage offered by the State of Delaware (“the State”). The ACA is requiring that these Notices be sent out because, starting in January 2014, most people are required to have health insurance; if not, they will pay a tax penalty. This is known as the “individual mandate.” Your health insurance coverage can come from your (or your spouse’s) employment, through a policy you buy on the Marketplace, or through a government-sponsored program like Medicare or Medicaid. As a full time employee, you are eligible to participate in the State’s Group Health Insurance Program (“the Plan”), and therefore do not need to shop for different or additional insurance through the Marketplace. The State’s coverage meets the individual mandate standard, and is expected to be a better value than Marketplace coverage. Here is how the Plan measures up under ACA criteria for determining whether a plan’s coverage is adequate and affordable for its participants: • In general, coverage is considered “minimum value” under ACA if the benefits the plan provides cover at
least 60% of eligible expenses. The Plan’s medical plans meet the ACA minimum value standard. • In general, coverage is considered “affordable” under the ACA if the premium cost for participant-only
coverage is not more than 9.5% of your household income. For example, if your household income (including your wages) is $40,000, your coverage would be considered affordable if your employee-only coverage does not cost you more than $3,800 a year. The Plan’s coverage is designed to be affordable.
Benefits and Insurance Administration – Benefits
500 W. Loockerman Street, Suite 320 • Dover, DE 19904 Phone (302) 739-8331 Fax (302) 739-8339 www.ben.omb.delaware.gov
Exchange Notice to Employees January 6, 2014 Page 2 The Notice mentions that you may be eligible for federal premium subsidies if you purchase coverage on the Marketplace, and that, if you do purchase a Marketplace plan, you may lose your employer contribution (if any) to the plan. Because the Plan meets the minimum value standard, you and your eligible family members would not qualify for a premium assistance tax credit to buy coverage through the Marketplace (if otherwise eligible based on your income and other factors) unless the Plan’s required contribution for self-only coverage made the coverage unaffordable. We encourage you to contact the Statewide Benefits Office if you have questions about the information in this letter or the enclosed Notice. You can call 1-800-489-8933 or go to the Statewide Benefits Office’s website at www.ben.omb.delaware.gov. You can also go to the State of Delaware website, www.ChooseHealthDE.com or the federal government’s website, www.HealthCare.gov. Sincerely,
Brenda L. Lakeman Director, Human Resource Management and Benefits Enclosure
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